1477338143 NPI number — MRS. STACEY LYNN CHISHOLM BCBA

Table of content: MRS. STACEY LYNN CHISHOLM BCBA (NPI 1477338143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477338143 NPI number — MRS. STACEY LYNN CHISHOLM BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHISHOLM
Provider First Name:
STACEY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477338143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 FACTORY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10990-1444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-988-1003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 FACTORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARWICK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10990-1444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-988-1003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-12-10196 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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